Acromegaly diagnosis.

The clinical presentation of acromegaly reflects systemic effects of chronic growth hormone (GH) and insulin-like growth factor 1 (IGF-I) excess. Diagnostic delay frequently ranges from 6 to 10 years. While classical manifestations such as acral enlargement and facial coarsening are diagnostically important, many patients initially develop nonspecific symptoms, including sleep apnea, carpal tunnel syndrome, arthralgia, and metabolic disturbances. The lack of symptom/comorbidity specificity highlights the need for improved screening strategies, particularly for patients without overt acral changes. Comorbidity cluster analyses, potentially supported by artificial intelligence, may facilitate earlier identification, prompting biochemical confirmation of the diagnosis. Biochemical evaluation has benefited from advances in hormone assay harmonization and the establishment of robust age-adjusted reference ranges. Serum IGF-I is the preferred initial screening test due to its stability and reflection of integrated GH secretion. However, interpretation of assay values should consider age, sex, assay variability, and confounding conditions such as diabetes, liver or renal disease, obesity, pregnancy, and estrogen exposure. For discordant biochemical and clinical findings, it is recommended to repeat IGF-I and to measure GH during an oral glucose tolerance test (OGTT). Although random GH levels are often elevated and correlate with somatotroph adenoma size, GH suppression during OGTT is the gold-standard confirmatory test, especially in patients with borderline results. The use of ultrasensitive GH assays has lowered the recommended nadir GH cut-off threshold to ∼0.4 µg/L, with assay-specific considerations. Advances in high-resolution MRI and PET/MRI, alongside AI-driven facial recognition, electronic medical record analysis, and radiomics, offer promising avenues for earlier and more accurate diagnosis of acromegaly.